Editor’s note: As some readers may know, one of the authors, Dr. Ledesma, died January 26, 2014, just before this column was finalized for publication. The other authors have included him in the byline because he gave the talk that served as the impetus for publishing a column on rural surgery in Argentina. Dr. Ledesma’s close friend, Dr. Pellegrini, attended the conference where the presentation was given, and translated it for use in this column. Dr. Ledesma died following a long battle against a malignant pheochromocytoma. He will be sorely missed by his wife and family and by the medical community of Viedma.
Rural surgery is an important component of the health care delivery system of any nation. All nations have rural areas, and all nations have difficulty providing surgical care to rural patients. More than 90 percent of unintentional injury deaths occur in low- and middle-income countries.1 The poorest third of the world’s population receives only 3.5 percent of the surgical procedures provided worldwide.2 To illustrate this discrepancy, a review of 132 district-level health facilities in eight low- and middle-income countries revealed that only 48 percent were capable of performing an appendectomy.3
Despite the vast differences between nations of the world, the barriers that prevent delivery of surgical care to rural areas can be quite similar. As a global surgical community, we can all learn from the successes of rural surgeons throughout the world.
The leadership of the American College of Surgeons (ACS) is aware of the problems that rural surgeons face and the issues that threaten the very viability of surgical care in communities outside of metropolitan areas. The current President of the ACS and one of the authors of this article, Carlos A. Pellegrini, MD, FACS, grew up as a son of a physician in Amenabar, Argentina, a province of Santa Fe and a community of approximately 400 people, and has considerable familiarity with the special problems that rural surgeons face.
In March 2013, Dr. Pellegrini attended the National Congress of Surgical Residents meeting in Rosario, Argentina. During the meeting, several Argentine surgeons were asked to speak about their careers. Dr. Pellegrini felt that the most compelling presentation was given by Carlos L. Ledesma, MD, a rural surgeon from Viedma, Argentina. (Drs. Pellegrini and Ledesma trained as surgical residents together and have remained close friends.) Dr. Ledesma spoke of his 40-year experience as a rural surgeon, described the differences between rural surgical practice and general surgery practice in a large town, and discussed what he believed were the fundamentals to success for a rural surgeon. Dr. Pellegrini was struck by the similarity of issues that rural surgeons face in Argentina and in the U.S. and found Dr. Ledesma’s insight and wisdom impressive.
The path to rural practice
How Dr. Ledesma became a rural surgeon is an interesting story in itself. He grew up in Rosario, a large Argentine city. After medical school, he began surgical residency at the National University of Rosario Hospital, a large university program of world renown. Dr. Ledesma performed well as a resident, and it was clear that he would become a successful surgeon. In 1974, while still a resident, Dr. Ledesma and his chair, Juan M. Acosta, MD, FACS(Hon), published a seminal article in the New England Journal of Medicine, “Gallstone Migration as a Cause of Acute Pancreatitis,” which plainly established the relationship between common bile duct stones and pancreatitis.4 Dr. Ledesma clearly was destined for great things in the field of surgery.
In Argentina, health care is available to all citizens. Patients with the financial means mostly choose to be cared for at private hospitals. For all others, care is provided at no cost at public hospitals. It is widely understood that public hospitals are somewhat second-rate in comparison with private hospitals. In fact, in 1974, the government of Argentina initiated a program to improve the quality of public hospitals. One goal of the initiative was to attract top physicians to public hospitals by paying them salaries similar to the earnings of physicians in the private sector. A pilot program was started in the region of Rio Negro, a province of Argentina, and a competition was held to select the surgeon who would take this position. It was a highly sought-after position, and both Dr. Ledesma and Dr. Pellegrini applied for it; as fate would have it, Dr. Ledesma won the competition.
After completing his residency in 1974, Dr. Ledesma and his young family moved to Viedma, the capital of Rio Negro with a population of approximately 20,000 citizens. His surgical practice flourished, but after several years, funding for the government program ended. Dr. Ledesma decided to stay in Viedma and he continued to practice there until his death in January.
Reflections on rural surgery
In his talk at the conference, Dr. Ledesma reflected on his career as a rural surgeon. When he first started his practice in Viedma, it became clear that his training had inadequately prepared him for the variety of surgical problems that he would encounter. He had to learn aspects of gynecologic surgery, orthopaedics, urology, pediatric surgery, and plastic surgery. For a rural surgeon to succeed, he or she must be willing to learn and practice elements of these other surgical specialties and, therefore, Dr. Ledesma strongly felt that specialized training in these areas is necessary.
It quickly became apparent to Dr. Ledesma that the pace of life in Viedma was much different than it was in Rosario. He described a “framework of relative peace and quiet,” which was a major change from the “frenzy” he had experienced through medical school and in training. He and his family found this change welcoming. A rural surgeon must be motivated to embrace this lifestyle and must develop a real sense of commitment to the members of the community that he or she serves.
“When you work in a very small town, the care that you provide [to] your patients is a lot more personalized,” Dr. Ledesma said. “You generate a stronger feeling and relationship between the physician, the patient, and the family.” A rural surgeon must be comfortable working with patients and their families in this way. Dr. Ledesma found it very easy to embrace this more personalized relationship and considered it a great benefit in practicing rural surgery.
Dr. Ledesma also learned that the size of the community can play a role in whether a rural surgeon can maintain a viable practice. He believed that a community needs to have a population of at least 10,000 to support a rural surgeon. He said he had seen attempts to set up a rural surgical practice in smaller communities, and, despite initial enthusiasm, these practices usually failed because they were often unable to sustain a hospital or clinic with the infrastructure needed to provide a viable practice for a rural surgeon.
The rural surgeon must be able to adapt to practice in a smaller medical community. For example, the surgeon will have fewer colleagues to offer help and advice. “One of my friends, a surgeon in another small town, was telling me that every time he was washing his hands in preparation for an operation just prior to entering the operating room, he felt lonely and compared himself to the bullfighter that is about to enter a major event where his life depends on his ability to make the outcome go his way,” Dr. Ledesma observed. He said that the way to combat these feelings of isolation is to form very close relationships with the other individuals in the medical community, so that everyone functions as a member of a team. “Offering consultation, advice, and support to others becomes a much more important element of one’s life when one lives in a smaller community,” he said.
A rural surgeon will be working in a setting where the infrastructure of the hospital and support staff are considerably smaller than in a large hospital. Hence, rural surgeons must be more active in the preoperative and postoperative care of patients. A rural surgeon needs to understand the level of care that he and his medical team are able to provide and must know when to refer a patient to a larger center.
Dr. Ledesma stressed the need for continued professional development. It is important to remain current and to learn new surgical techniques. It certainly is easier for rural surgeons to participate in educational programs in the Internet era, but it is up to them to make continued professional development a priority. He also emphasized the importance of being active in surgical organizations. He was a longtime member of the Argentine Association of Surgeons and attended their Clinical Congress every year. He and his local colleagues organized an annual Spring Congress of the Argentine Association of Surgery in their region. These activities helped the surgical community in their region function as a team, which has been valuable in bringing new surgical techniques, such as laparoscopic surgery, to their area.
Common concerns
Dr. Ledesma clearly thrived as a rural surgeon and derived a deep level of satisfaction from his work. At the conclusion of his talk, he stated, “Small communities provide for a special and a different quality of life. The peace inherent to the smaller community, the proximity to home and family, the ability to take the kids to school, to see patients and friends alike, to engage in community affairs, and to be considered a leader within the environment is very much a part of the life I cherish. To me, the ability to walk to work, to come back home for lunch with the family, to see friends in the community every single day, and to realize the impact that I have in that community provides meaning and purpose to my life, and the very best quality of life I could ever have dreamed of.”
Rural surgery clearly is a worldwide issue, with all nations struggling to deliver surgical care to rural areas. Despite major differences in nations, it is clear that many of the issues facing rural surgery are similar from nation to nation. The fundamentals for success for a rural surgeon in Argentina are the same fundamentals that would bring success in America, and in many other nations. As rural surgeons, we need to function as a worldwide team, to learn from the success of others, and to work together to solve the common problems facing rural surgery.
References
- Peden M, McGee K, Krug E. Injury: A Leading Cause of the Global Burden of Disease. 2000. Geneva: World Health Organization; 2002.
- Weiser TG, Regenbogen SE, Thompson KD, Haynes AB, Lipsitz SR, Berry WR, Gawande AA. An estimation of the global volume of surgery: A modeling strategy based on available data. Lancet. 2008;372(9633):139-144.
- Kushner AL, Cherian MN, Noel L, Spiegel DA, Groth S, Etienne C. Addressing the Millennium Development Goals from a surgical perspective: Essential surgery and anesthesia in eight low- and middle-income countries. Arch Surg. 2010;145(2):154-159.
- Acosta JM, Ledesma CL. Gallstone migration as a cause of acute pancreatitis. N Engl J Med. 1974;290(9):484-487.
